RESUMO
Patients receiving extracorporeal membrane oxygenation (ECMO) may display large decreases in drug concentrations due to increases in volume of distribution and drug binding to ECMO circuits, tubing, oxygenator, and coating materials. We report a case of a critically ill male with a 10-month status post-deceased donor renal transplant and being treated with voriconazole for suspected aspergillosis. Initially, multiple dose increases, up to 11.3 mg/kg/dose, were required while on ECMO therapy to obtain goal voriconazole trough concentrations between 2 and 5.5 mcg/mL. The patient's voriconazole dose requirement subsequently decreased to 7.3 mg/kg/dose after ECMO discontinuation, which represented a 45% reduction in voriconazole dose requirement. Based upon this experience, voriconazole appears to bind to artificial surfaces on ECMO devices. In addition to close monitoring of trough levels, it may be appropriate to empirically reduce the voriconazole dose in patients after ECMO discontinuation.
Assuntos
Oxigenação por Membrana Extracorpórea , Estado Terminal , Humanos , Masculino , VoriconazolRESUMO
OBJECTIVE: To describe a case of BK virus encephalitis with attempted direct antiviral therapy, review the reported cases of BK virus in the central nervous system, and report the novel use of intravenous cimetidine in place of oral probenecid to minimize the toxicities of intravenous cidofovir. CASE SUMMARY: A 36-year-old male with acute myelomonocytic leukemia and subsequent myelodysplastic syndrome underwent allogeneic hematopoietic stem cell transplant. His course was complicated by severe graft-versus-host disease involving his skin and gastrointestinal tract. Five weeks after transplantation, he developed fever and confusion. Magnetic resonance imaging was suggestive of limbic encephalitis and cerebrospinal fluid tested positive for BK virus. Therapy with intravenous cidofovir was thought to be indicated. Although probenecid is commonly used to minimize the toxicities of cidofovir, the patient's severe graft-versus-host disease raised concerns about absorption of oral medications. Based on animal models and pharmacokinetic data, intravenous cimetidine was used in place of oral probenecid. Despite these therapies, the patient's mental status did not improve. He developed progressive organ system failure, and care was ultimately withdrawn. DISCUSSION: BK virus is increasingly described as a cause of encephalitis. The majority of reported cases have occurred in immunocompromised patients and have generally had a poor outcome. This case describes attempted antiviral therapy using cidofovir, the antiviral agent used most frequently in other syndromes due to BK virus. Intravenous cimetidine is a novel modality used to minimize ocular and renal toxicities frequently seen with cidofovir, and we believe this warrants further investigation. CONCLUSIONS: BK virus may be a cause of encephalitis in immunocompromised hosts, and cidofovir represents a possible treatment option. Intravenous cimetidine can be considered to minimize toxicities associated with cidofovir use in patients unable to tolerate or absorb oral probenecid.
Assuntos
Antivirais/uso terapêutico , Vírus BK , Citosina/análogos & derivados , Encefalite/tratamento farmacológico , Organofosfonatos/uso terapêutico , Infecções por Polyomavirus/tratamento farmacológico , Infecções Tumorais por Vírus/tratamento farmacológico , Adulto , Cidofovir , Citosina/uso terapêutico , Humanos , MasculinoAssuntos
Antígenos de Protozoários/sangue , Testes Diagnósticos de Rotina/normas , Malária Falciparum/diagnóstico , Mycoplasma pneumoniae/imunologia , Pneumonia por Mycoplasma/diagnóstico , Viagem , Adulto , Sudeste Asiático , Diagnóstico Diferencial , Reações Falso-Positivas , Feminino , Humanos , Malária Falciparum/sangue , Mycoplasma pneumoniae/genética , Plasmodium falciparum , Pneumonia por Mycoplasma/sangue , Sensibilidade e Especificidade , Estados UnidosRESUMO
Central venous catheters have become a mainstay in the care of critically ill patients but, unfortunately, are associated with a significant risk of bloodstream infections. There are 80,000 catheter-related bloodstream infections that occur annually in the United States, with a high human and financial cost. This paper reviews the main tools for prevention and diagnosis of central venous catheter-related bloodstream infections in the intensive care unit. We discuss specific aspects of prevention, including education, hand hygiene, sterile technique, skin cleansing, choice of catheter site, antimicrobial-impregnated catheters, catheter site dressings, antibiotic lock solutions, anticoagulation, catheter changes, and needleless connection devices. An analysis of studies evaluating the use of catheter "bundles" is also included. Diagnostic methods discussed include how to obtain blood cultures, when to culture catheter tips, how to interpret culture results, and the best methods for diagnosis.
Assuntos
Bacteriemia/prevenção & controle , Infecções Relacionadas a Cateter/prevenção & controle , Infecção Hospitalar/prevenção & controle , Controle de Infecções/métodos , Unidades de Terapia Intensiva , Anti-Infecciosos/administração & dosagem , Antibioticoprofilaxia , Anticoagulantes/uso terapêutico , Bacteriemia/diagnóstico , Bandagens , Infecções Relacionadas a Cateter/diagnóstico , Cateterismo , Infecção Hospitalar/diagnóstico , Desinfecção , Desinfecção das Mãos , Humanos , Capacitação em Serviço , Guias de Prática Clínica como Assunto , Esterilização , Trombose Venosa/prevenção & controleRESUMO
We report the first case, to our knowledge, of Blastoschizomyces capitatus infection occurring in a patient receiving empirical echinocandin therapy for neutropenic fevers. Clinicians should consider B. capitatus infection in those neutropenic patients who remain febrile despite echinocandin therapy or who develop yeast bloodstream infections while receiving an echinocandin.
Assuntos
Antifúngicos/uso terapêutico , Equinocandinas/uso terapêutico , Geotricose/complicações , Geotrichum/fisiologia , Lipopeptídeos/uso terapêutico , Neutropenia/complicações , Neutropenia/tratamento farmacológico , Idoso , Evolução Fatal , Geotricose/microbiologia , Geotrichum/isolamento & purificação , Humanos , Masculino , Micafungina , Testes de Sensibilidade MicrobianaRESUMO
We analyzed national foodborne outbreak data from 1973 through 2001 to determine the proportion of Salmonella Heidelberg outbreaks caused by specific foods. Among 6633 outbreaks with known etiology, 184 (3%) were caused by Salmonella Heidelberg. A vehicle was identified in 101 outbreaks; at least 53 were poultry or egg-related. Three outbreaks were attributed to egg consumption, 17 to consumption of egg-containing foods, 25 to poultry, and 8 to foods containing poultry and eggs. Efforts to reduce illness due to Salmonella Heidelberg shouldensure that poultry and eggs are handled appropriately to minimize contamination and cross contamination.
Assuntos
Surtos de Doenças/prevenção & controle , Ovos/microbiologia , Contaminação de Alimentos/análise , Intoxicação Alimentar por Salmonella/epidemiologia , Intoxicação Alimentar por Salmonella/prevenção & controle , Adulto , Animais , Qualidade de Produtos para o Consumidor , Feminino , Manipulação de Alimentos/métodos , Microbiologia de Alimentos , Humanos , Masculino , Pessoa de Meia-Idade , Aves Domésticas , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Contact isolation is a method used for limiting the spread of antimicrobial-resistant organisms when caring for patients. This policy has been linked to several adverse outcomes and less patient satisfaction. We assessed patient and caregiver understanding and satisfaction with the use of contact isolation. METHODS: A prospective survey of >500 patients in contact isolation at our institution was performed during 2014. Participants responded to a series of statements relating to contact isolation, using a 5-point Likert scale. Responses were assessed for overall positivity or negativity and further compared according to floor type or designation. RESULTS: Of the patients, 48.7% responded to the survey; 70 caregivers also responded. Patient and caregiver responses were similar and were positive overall. Most respondents felt safer because of the use of contact isolation and because it prevented infections. A smaller majority of respondents also thought the policy was adequately explained to them and adhered to by staff. CONCLUSIONS: In the largest collection of respondents surveyed to date about contact isolation and its impact on them, the policy was viewed positively, both by patients and caregivers. There is still room for improvement in the area of patient education regarding the use of contact isolation.
Assuntos
Cuidadores , Compreensão/fisiologia , Isolamento de Pacientes/psicologia , Pacientes , Satisfação Pessoal , Humanos , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
The risks and microbiology for peripherally inserted central catheters (PICCs) are less well described than those for traditional central catheters, particularly as they pertain to duration of catheterization. We compared patients with early- and late-onset PICC bloodstream infections at our institution and found significant differences in microbiologic etiologies.
Assuntos
Infecções Relacionadas a Cateter/etiologia , Cateterismo Venoso Central/efeitos adversos , Cateterismo Periférico/efeitos adversos , Infecção Hospitalar/etiologia , Candidíase/etiologia , Candidíase/microbiologia , Infecções Relacionadas a Cateter/microbiologia , Infecção Hospitalar/microbiologia , Infecções por Enterobacteriaceae/etiologia , Infecções por Enterobacteriaceae/microbiologia , Humanos , Staphylococcus aureus Resistente à Meticilina , Estudos Retrospectivos , Fatores de Risco , Infecções Estafilocócicas/etiologia , Infecções Estafilocócicas/microbiologia , Fatores de TempoRESUMO
We describe an outbreak of Pseudomonas aeruginosa respiratory tract infections related to intrinsically contaminated ultrasound gel used for intraoperative transesophageal echocardiograms in cardiovascular surgery patients. This investigation led to a product safety alert by the Food and Drug Administration and the development of guidelines for appropriate use of ultrasound gel.